This study of 12 countries provides an overview of recent changes in national governments' role in the governance of health systems, focusing on efforts to reconfigure responsibilities for health policy, regulation and management; the resultant policy priorities; and the initial impact. The shift in responsibilities shows little uniform direction: a number of countries have centralized certain areas of decision-making or regulation but decentralized others. The study reviews common trends, based on the country cases, and assesses potential future developments.